ACL Reconstruction or Repair with Suture Augmentation Allows Early Rehabilitation: Collagen Co-braid Sutures May Improve Biological Integration.

Suture augmentation in anterior cruciate ligament (ACL) reconstruction has the potential to combine improved long-term stability and high functional outcomes with accelerated rehabilitation, enhancing the biomechanical properties of the graft, and reducing the risk of graft failure, particularly during the critical early phases of rehabilitation. Suture augmentation, applied to either ACL reconstruction or to primary repair, introduces a "safety belt" synergistically sharing loads acting on the graft or repair. Several biomechanical studies utilizing different autologous grafts for ACL reconstruction, as well as studies on ACL repair, have demonstrated that suture augmentation enhances strength and prevent elongation of the graft or ligament. Suture augmentation can protect the graft-brace integrity under loads of 350N, and reduces cyclic displacement by up to 31% compared to conventional ACL reconstruction using bone-patellar tendon-bone allograft. Perhaps, as above, the greatest advantage of suture augmentation is allowing early rehabilitation. Assuming successful ligamentization of the graft, the graft itself should stabilize the knee joint, thereby diminishing the long-term benefit of suture augmentation. In practice, we utilize suture augmentation to support immediate postoperative mobilization and weight-bearing, enabling safe and early rehabilitation, while minimizing the risk of failure. With regard to the oft-mentioned risk of over-constraint, this is not supported by biomechanical studies or clinical experience. Recent introduction of collagen co-braid sutures for suture augmentation offer two distinct advantages: first, potentially improved biocompatibility, and second, gradual biological integration allowing suture degradation over time.